en-US1 en-USAPPLICATION AND INSTRUCTIONSen-USCRIME VICTIMS COMPENSATION PROGRAM en-USINSTRUCTIONSen-USTen-USo expedite the processing of your en-USapplication, please submit a en-USComplete en-USApplication Packeten-US, whichen-US includes items 1 en-USthru 3 below. 1 en-US en-USPlease complete the entire application, en-USprinting clearly. Sign every place where an en-USoriginal signature is requested. 2 en-USProvide us with a police or incident report en-USthat lists the victim or witness name, and a en-USsummary of the incident. 3 en-USSubmit at least one itemized bill for services en-USrelated to the crime, or all of the documents en-USfor Economic Support. A complete list en-USof the documents required for Economic en-USSupport is available on our website. 4 en-USMail the complete application packet toen-US en-USCriminal Justice Coordinating Council, en-USCrime Victims Compensation Programen-US104 Marietta Street NW, Suite 440en-US en-USAtlanta, GA 30303en-USIf you would like help completing your en-USapplication, or if you have questions, please en-UScall us. We have Program Advocates en-USavailable to assist you.en-USO037ce (404) 657-2222en-USToll Free (800) 547-0060en-USTTY (404) 463-7650en-USFax (404) 463-7652en-UScrimevictimscomp.ga.gov en-USThe Georgia Crime Victims Compensation Program (CVCP) may en-USbe able to ease the 036nancial burden incurred by innocent victims en-USand witnesses of crime, when other resources are exhausted. en-USEligible program applicants can receive compensation of up en-USto $25,000 to help with medical and dental care, counseling, en-USeconomic support, crime scene sanitization, and funeral expenses en-USwhen the costs are not covered by other sources.en-USBENEFITS COVEREDen-USMedical and Dental Expenses þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. þ .. en-USUP TO $15,000en-USEconomic Support Expenses þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . en-USUP TO $10,000en-USFuneral Expenses þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . en-USUP TO $6,000*en-USCounseling Expenses þ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . en-USUP TO $3,000**en-USCrime Scene Sanitization Expenses þ . . . . . . . . . . . . . . . . . . . . . . en-USUP TO $1,500en-US en-USPLEASE NOTE þ en-USIf you do not have some or all of the required en-USdocumentation (such as an itemized bill or police report), en-USyou may still submit a signed application to begin the claim en-USreview process. Your claim will be incomplete and we will en-USfollow up with you for the additional documents that are en-USneeded. þ You may also submit an application even if there is no en-USknown o035ender. While the incident must be reported to law en-USenforcement or an investigative agency (DFCS, APS, the en-UScourts, medical authorities, or the school system), arrest en-USand/or prosecution of an o035ender is not a program or en-USeligibility requirement. þ In addition to mailing your en-USComplete Application Packeten-US, en-USyou may also fax or email it to start a claim, but we will en-USrequire an application with your original signature in order en-USto fully process your application. You may also bring the en-USComplete Application Packet to our o037ce. þ You may be asked to complete a medical release form when en-USrequesting medical or counseling bene036ts. Submitting en-USthe release with your Complete Application Packet may en-USexpedite processing. þ We are the payor of last resort. We cover expenses not en-USpaid by insurance, including Medicaid/Medicare or other en-USmonetary resources. þ en-USBene036ts received are based on actual eligible expenses and en-USitemized bills must be submitted with your application for en-USreview. A death certi036cate must be submitted with your application for þ en-USfuneral bene036ts. For crimes prior to May 6, 2015, the categorical cap is en-US$3,000.en-USPlease refer to our website for the counseling bene036ts fee schedule.en-US*en-US** American LegalNet, Inc. www.FormsWorkFlow.com en-USAPPLICATIONen en-USCRIME VICTIMSen-USCOMPENSATION en-USSECTION 1. en-USVICTIM/WITNESS INFORMATIONen-USPlease provide information on the individual who was killed or injured as a result of a violent crime, or who en-USwitnessed a violent crime.en-USVictim/Witness Name (First, Middle, Last)en-USGenderen-USen-USMale en-USen-USFemaleen-USDate of Birth (MM/DD/YY)en-US / / en-USSocial Security Number (or TIN)en-USStreet Address (including apartment #)en-USCityen-USStateen-USZip Codeen-USBest Contact Phone Numberen-USAlternate Phone Numberen-USEmail Addressen-USHow would you like to receive claim updates? en-USen-USEmail en-USen-USMailen-USDemographic Data (For Statistical Use Only) Race: þ en-US American Indian/Alaska Native þ en-US Asian þ en-US Black/African American þ en-USen-USNative Hawaiian and Other Paci037c Islander þ en-US White/Non-Latino/Caucasian þ en-US Hispanic/Latino þ en-USen-USOther Race en-USIf 17 or older, is the victim a veteran?en-US en-USen-USYes en-USen-USNo en-USIs the victim disabled? en-USen-USYes en-USen-USNo en-USIf yes, is the disability as a result of the crime? en-USen-USYes en-USen-USNoen-USPage 1 of 2en-USwww.crimevictimscomp.ga.gov en-US104 Marietta Streeten-USSuite 440 en-US en-USAtlanta, GA 30303en-USO036ce (404) 657-2222 en-USFax (404) 463-7652 en-USToll Free (800) 547-0060 en-USTTY (404) 463-7650 en-USSECTION 3. en-USCLAIMANT INFORMATIONen-USComplete this section if you are 037ling on behalf of a deceased victim, minor victim, incapacitated adult victim, or en-US en-USif you are not the victim, but are paying bills on behalf the victim.en-USClaimant Name (First, Middle, Last)en-USGenderen-USen-USMale en-USen-USFemaleen-USDate of Birth (MM/DD/YY)en-US / / en-USSocial Security Number (or TIN)en-USStreet Address (including apartment #)en-USCityen-USStateen-USZip Codeen-USRelationship to Victim/Witnessen-USBest Contact Phone Numberen-USAlternate Phone Numberen-USEmail Addressen-USHow would you like to receive claim updates? en-USen-USEmail en-USen-USMailen-USDemographic Data (For Statistical Use Only) Race: þ en-US American Indian/Alaska Native þ en-US Asian þ en-US Black/African American þ en-USen-USNative Hawaiian and Other Paci037c Islander þ en-US White/Non-Latino/Caucasian þ en-US Hispanic/Latino þ en-USen-USOther Race en-USAre you a veteran?en-US en-USen-USYes en-USen-USNo en-USAre you disabled?en-US en-USen-USYes en-USen-USNo en-USSECTION 2. en-USSECONDARY CONTACT INFORMATIONen-USIf your contact information above changes, please provide information for a person we can contact to reach you en-USabout your claim. en-USPlease Note:en-US We will not disclose any information about the claim to your secondary contact.en-USVictim/Witness Name (First, Middle, Last) Best Contact Phone Number en-USAlternate Phone Number en-USSECTION 4. en-USBENEFITS REQUESTEDen-USPlease complete this section by checking all the bene037ts you are applying for and submit itemized bills for en-USservices related to the crime. en-USPlease Note:en-US a death certi037cate is required for funeral bene037ts.en-USen-US en-USMedicalen-USen-USLoss of Incomeen-USen-USLoss of Supporten-USen-USCounselingen-USen-USFuneral/Burialen-USen-USCrime Scene Sanitizationen-USPlease Note:en-US If applying for loss of income, you cannot be reimbursed if your wages were fully covered (e.g., sick or annual leave, vacation, disability etc.) while you en-USwere out due to the crime. If eligible, you can only be reimbursed when you missed work and were not paid, or your wages were only partially covered.en-USWas the victim or witness gainfully employed at the time of the crime? en-USen-USYes en-USen-USNoen-USIf yes, please provide the date(s) the victim or witness was out of work due to the crime: en-USPlease check if you have requested/037led for: en-USen-USRestitution en-USen-USWorkers Compensation en-USen-USLawsuit/Civil Action en-USIf bene037ts are awarded, please indicate if you would like to receive Direct Deposit (ACH Payment) or a Check en-USen-USDirect Deposit (ACH Payment)* en-USen-USChecken-US*Please Note:en-US